NYT Article on Medication & Behaviorial Training for ADHD

[Crimson Wife]

I did start my DD on Applied Behavioral Analysis therapy prior to adding medication and that's what the researchers found was the most effective order (though they looked at group parental training rather than 1:1 behavioral therapy): http://www.nytimes.com/2016/02/18/health/early-behavior-therapy-found-to-aid-children-with-adhd.html

 

That said, we saw significant improvement after we added medication and better results with a combo of a stimulant (methylin) and a non-stimulant (clonidine) than with either medication alone. So I don't think behavioral therapy/training by itself is enough for all kids (which is what the researchers found as well).

[nature girl]

This is interesting! But I wonder if it's their theory is correct, that it's because the parents who started with meds decided the behavioral therapy was too much work for not enough of a difference, so didn't keep up with the program like the non-med parents did?

 

Anna's starting therapy in 2 weeks, we'll see how far it takes us. I'm not all that hopeful...I just don't think she'll put up with it, or be willing to talk about anything with the therapist. Unfortunately she'd probably NEED meds to be able to put up with it. But we've been consistently using rewards/consequences much more consistently since last summer, and it seems to be making a ton of difference, she still has behavior and emotional regulation issues, but she's not the same kid as she was last June.

 

A little sidetrack, but one quote I'm wondering about:

"And they learn to ignore irritating but harmless bids to win attention, like making weird noises, tapping or acting like a baby."

We don't say anything with actions that are just irritating, but this makes me wonder if I should be ignoring more. Like she HATES using a fork, and seeing her jam food in her mouth with her hands really gets to me so I always speak sternly to her. Is that the kind of thing that should be ignored (and if so will it ever get better?) Also leaning on my head or throwing toys across the room when she's frustrated with them, that sort of thing, which aren't really that big a deal but are still something I want her to learn how to control. I don't punish her for it, but I don't ignore it either.

[Lecka]

I think there is context for that quote. I don't think it is true forever, just if they are starting out and maybe it is a bit of a distraction. Maybe it starts out at "something to ignore for now" but when there is general improvement then it is time to address it.

 

Since it says attention-seeking, too, that could mean that those things were actually identified as attention-seeking in the example.

 

But no, I don't think it is blanket advice to ignore things like that.

 

Edit: personally I did get advice 3 years ago to ignore some things, that I would never ignore now. Bc our situation has changed a lot and it is very appropriate to hold my son accountable to higher standards.

 

But he also had some entenched attention-seeking behavior, and now he had got (overall) good ways to seek attention that are easy for him and that he just does now.

 

So now I would not ignore things that I would have ignored back when the situation was different.

Edited February 18, 2016 by Lecka

[kbutton]

I'm with Anna's Mom on the questions--we get that stuff here. I am not a leaning post. If they want to use me as one, then I will be exorbitantly cranky. Ignoring most things do not make them go away. There are lots of things we do ignore when it helps, but this kind of irritating stuff does NOT. It's a "make me happy because I feel funny inside that things are hard" or something like that. Well, kiddo, things are going to continue to get harder, and I can't just stop teaching you things. We have reached an impasse. The psych that evaluated my littler one admitted that if I don't keep him moving forward he'll be bored, but clearly the ADHD is interfering big time. I modify a lot of things already.

 

I think these are also salient paragraphs:

"Other experts cautioned that the study tracked behavior but not other abilities that medication can quickly improve, like attention and academic performance, and said that drugs remained the first-line treatment for those core issues.

 

“I think this is a very important study, and the take-home is that low-cost behavioral treatment is very effective,†said Mark Stein, a professor of psychiatry and pediatrics at the University of Washington, “but the irony is that that option is seldom available to parents."

 

We have two kiddos with ADHD, and they are TOTALLY different with different problems. I can state that inattentive behavior does not seem to respond to anything but meds in our case. I can add and withhold privileges all day, and it does nothing. They can't make themselves attend once they reach a level of thinking or multi=tasking that means they are doing meaningful work.

 

I also agree that few places really offer meaningful behavioral therapy. When they do, they probably have a lot of misconceptions to work through. Also many parents have worked, worked, worked (potentially ineffectively) for a long time to avoid meds and support their kids, and they are just DONE by the time they ask for meds. The question of "have you tried...?" from a clinician at that point is insulting. It doesn't matter if the parents have had EFFECTIVE strategies or TERRIBLE ones because they are fried. At least that's where we are/were. At least one of my kids is so clueless that tracking anything to give even small, instant rewards is mind=numbingly difficult (and he feels like if he doesn't always make it and get the reward, he's failed), and the other one games the system. This is, after all, the kid that we could not use rewards with for pottying. If we gave him a balloon when he went pee, he wanted a balloon + x next time. Pooping? Well, nothing short of an absolute monarchy established by him was going to be satisfying, lol!

 

So, no argument from me about the results of the article or assertions that behavioral stuff does not work, but a huge load of "but what about this" comes to mind when I read it.  :lol:  I really think that professionals who do these studies should offer suggestions on when to seek this behavioral help and how to somehow acquire it without suggesting inadvertently that the parent is doing something wrong when they adjust and support their children to no avail. Really, people beat their heads against the wall BEFORE going to the doctor unless school pressures are breathing down their neck.

 

I very much appreciate you posting it. It's a sane and informative piece.

[Heathermomster]

A trip to a highly experienced OT that understands retained reflexes would be extremely helpful prior to a rewards based system.  A child with an active STNR cannot be expected to sit still.  My child is ADHD inattentive and doesn't act annoying for attention, but he did move around a lot.  The movement stopped with OT and pediatric PT work to address the reflexes and the poor posture he had developed in order to sit still at a desk.  Otherwise, the CBT that I spoke with yesterday agrees that the best outcomes involve behavior therapy and drugs. ETA.  If drugs work without the weekly 2hr visit (drive and wait and copay) to a therapist, why would a parent bother with therapy? 

Edited February 18, 2016 by Heathermomster

[kbutton]

Lecka, that's a helpful answer. Much more nuanced than the article can be.

[Crimson Wife]

 

  Also many parents have worked, worked, worked (potentially ineffectively) for a long time to avoid meds and support their kids, and they are just DONE by the time they ask for meds. The question of "have you tried...?" from a clinician at that point is insulting. It doesn't matter if the parents have had EFFECTIVE strategies or TERRIBLE ones because they are fried. At least that's where we are/were.

 

 

Not to sound too smug, but we homeschoolers/"afterschoolers" are not the typical parents. There are a LOT of parents who are looking for the easy way out when it comes to childraising because they're preoccupied with their careers and other personal concerns. It actually makes me very concerned for the future of this country, but that's another post. Pharmaceutical treatment of AD(H)D is most often the first resort rather than the last resort because it's much less work for the parent to give a pill than to do effective behavioral management.

[Lecka]

It doesn't sound like this is the reason given in the article, but ignoring of comparatively minor things can also help when the parent-child dynamic has gotten very poor.

 

Also what if the parent says "is there homework tonight," cue the dinner time annoyance, but it serves as a distraction to "is there homework."

 

So those are other times I think ignoring certain things or else ignoring minor things while NOT ignoring certain major things can be good, too.

 

Honestly ignoring is a major, major tool for me. MAJOR.

 

But my son tends toward using behavior to escape tasks, so there are times I need to ignore things in order to follow through.

 

It helps me stay focused to know if something is happening, things intending to get out of it will be ignored.

 

Or maybe not full-on ignoring, but I want to set the agenda sometimes, not just be in response mode.

 

But also -- we do not think this son has ADHD or impulsive (beyond the usual for the age) behavior.

 

It is just something where we have a lot of "if I do this, what will happen?"

 

And if what will happen is "I don't have to do what I was just told to do" then he would be very happy to do whatever that thing is! So a lot of times I need to ignore those things.

[nature girl]

It doesn't sound like this is the reason given in the article, but ignoring of comparatively minor things can also help when the parent-child dynamic has gotten very poor.

 

Also what if the parent says "is there homework tonight," cue the dinner time annoyance, but it serves as a distraction to "is there homework."

 

So those are other times I think ignoring certain things or else ignoring minor things while NOT ignoring certain major things can be good, too.

 

Honestly ignoring is a major, major tool for me. MAJOR.

 

But my son tends toward using behavior to escape tasks, so there are times I need to ignore things in order to follow through.

 

It helps me stay focused to know if something is happening, things intending to get out of it will be ignored.

 

Or maybe not full-on ignoring, but I want to set the agenda sometimes, not just be in response mode.

 

But also -- we do not think this son has ADHD or impulsive (beyond the usual for the age) behavior.

 

It is just something where we have a lot of "if I do this, what will happen?"

 

And if what will happen is "I don't have to do what I was just told to do" then he would be very happy to do whatever that thing is! So a lot of times I need to ignore those things.

 

Ugh, yes. Anna has this thing she does when I ask her to do something she doesn't want to. She circles her upper body around and around slowly while she's baring her teeth in this wide fake smile, it reminds me of the chicken neck that teenagers do except super-exaggerated, and she knows it drives me up the wall. I've been ignoring it for the past month or so even though I'm all scrunched up inside and it still hasn't stopped. PLEASE GOD make it stop!!! LOL...

[nature girl]

 

I'm with Anna's Mom on the questions--we get that stuff here. I am not a leaning post. If they want to use me as one, then I will be exorbitantly cranky. Ignoring most things do not make them go away. There are lots of things we do ignore when it helps, but this kind of irritating stuff does NOT. It's a "make me happy because I feel funny inside that things are hard" or something like that. Well, kiddo, things are going to continue to get harder, and I can't just stop teaching you things. We have reached an impasse. The psych that evaluated my littler one admitted that if I don't keep him moving forward he'll be bored, but clearly the ADHD is interfering big time. I modify a lot of things already.

 

 

I don't know if this will be helpful to you at all, but there was a webinar from ADDitude today titled "How Mindset Impacts Learning." Most of the information she gave wasn't altogether new (like praising effort over smartness), but she did give some new strategies I'm going to try.

[nanette0269]

Just curious...we just started STNR for some mild-moderate ADD.  How long was it before you noticed a difference? 

 

A trip to a highly experienced OT that understands retained reflexes would be extremely helpful prior to a rewards based system.  A child with an active STNR cannot be expected to sit still.  My child is ADHD inattentive and doesn't act annoying for attention, but he did move around a lot.  The movement stopped with OT and pediatric PT work to address the reflexes and the poor posture he had developed in order to sit still at a desk.  Otherwise, the CBT that I spoke with yesterday agrees that the best outcomes involve behavior therapy and drugs. ETA.  If drugs work without the weekly 2hr visit (drive and wait and copay) to a therapist, why would a parent bother with therapy? 

 

[Heathermomster]

Just curious...we just started STNR for some mild-moderate ADD.  How long was it before you noticed a difference? 

STNR exercises were coupled with interactive metronome (IM) therapy.  Son's trumpet tutor noted the differences in attention a month or so after we were done with OT.  The trumpet tutor called me after a lesson to talk about it.  I never really noted a huge difference.  Like, there was no shazam moment for me until after pediatric PT, and DS finally learned to swim.

 

DS required exercises for static/dynamic balance and posture too, but we didn't receive that therapy until much later when he was a 9th grader.  

 

If you note any slumping or poor posture after the reintegration exercises, try to find a good pediatric PT.  PT work involved weights, cross body work, agility, and balance exercises and took maybe 10 hourly sessions and daily homework.  

 

ETA: I should add that DS is primarily inattentive and is trying non-stimulant meds under the supervision of a child psychologist and just started CBT for the EF issues.

Edited February 18, 2016 by Heathermomster

[kbutton]

Not to sound too smug, but we homeschoolers/"afterschoolers" are not the typical parents. There are a LOT of parents who are looking for the easy way out when it comes to childraising because they're preoccupied with their careers and other personal concerns. It actually makes me very concerned for the future of this country, but that's another post. Pharmaceutical treatment of AD(H)D is most often the first resort rather than the last resort because it's much less work for the parent to give a pill than to do effective behavioral management.

 

I think this is true in some cases and that we probably are different in that regard. I would say, in our area, there is a lot of not wanting meds. You definitely have a bigger population size to sample in your area. :-) 

 

Just curious...we just started STNR for some mild-moderate ADD.  How long was it before you noticed a difference? 

 

I know you were asking Heather, but I would note that we still have significant ADHD left after working on reflexes. Things are better, for sure, but it only helped the bodily agitation that goes with the reflex being there, just as the vision therapy helped only the parts of his distraction that were due to visual things being hard. So, things are much better, much easier, and he's still a leaf in the wind. He's just less emotional, less jumpy, less frustrated over handwriting, and not skipping words while reading (which was blamed on ADHD).

[Crimson Wife]

OT has definitely been helpful in calming DD down (not as much as ABA but still worth the co-pays & time) and it was one of the things that we started prior to medication.

 

The whole "retained reflexes" hypothesis is controversial so I'm going to leave that as a YMMV thing. If you find the exercises helpful for your child, fantastic. Sometimes things work for reasons other than the claimed one (like acupuncture releases endorphins in the body even if all the Eastern mysticism about "chi" is bunk).

[Heathermomster]

All good points above.  My DS still is inattentive ADHD and is not on the spectrum, so we have to careful about comparing outcomes.  ETA:  Obvious positive outcomes related to reflex work are likely to be seen in the arena of VT work.

Edited February 18, 2016 by Heathermomster

[nature girl]

I think I'm confused. Anna's hyperactive when she's struggling to focus, so while doing work, or sometimes while being read to. I thought jiggling was a way of blocking out other stimuli, no? Could it be the result of a retained reflex? How does this relate? Does working on retained reflexes ever help with attention and EF skills? (She's only mildly sensory-seeking, so even if that was resolved she'd still have attention and emotional regulation issues.)